Bakgrund: Alla, som vårdas inom rättspsykiatrisk vård, har någon form av psykiskt funktionshinder och har också begått ett eller flera brott. Vården regleras av ett antal lagar. I rehabiliteringen ingår utslussning av patienten till öppna vårdformer genom så kallad permission. Ett antal av de patienter som har permission återintas emellanåt till slutenvården av olika orsaker. De benämns ibland som svängdörrspatienter. Syfte: Syftet var att belysa olika berörda personalgruppers syn på och erfarenheter av vad som har betydelse för om en patient som vårdas enligt lagen om rättspsykiatrisk vård, lyckas eller misslyckas med sin permission. Metod: En kvalitativ ansats valdes och två fokusgruppsintervjuer med sex deltagare i varje grupp genomfördes. Texten analyserades med hjälp av en kvalitativ innehållsanalys. Resultat: Tre huvudteman som hade betydelse för om en permission lyckades framkom: samsjuklighet, hur grundläggande behov mötts och samverkan runt patienten. Under dessa framkom 14 subteman: rätt psykiatrisk diagnos, samtidigt missbruk, följsamhet i medicinering, socialt nätverk, sysselsättning, tryggt boende, patientens ekonomi, se patientens behov, tydlig planering, kunskap och motivation, otydlig ansvarsfördelning, samverkan inför permission, kontaktmannaskap och uppföljning i öppenvård. Konklusion: Mycket fungerar bra i vården runt patienten inom rättspsykiatrisk vård. Brister finns dock som behöver förbättras och utvecklas. Det är viktigt att patienterna är delaktiga i vården och att olika instanser skapar individuella förutsättningar och flexibla lösningar för att permissionen ska lyckas. Ordnad ekonomi är av stor betydelse för att permissionen ska lyckas, då det påverkar många delar i patientens vardag. När patienten misslyckas med permissionen kan orsaken vara att man inte har tagit reda på dennes verkliga behov eller inte tagit tillräcklig hänsyn till dessa i permissionsplaneringen. Bristande resurser i samhället bidrar ibland till att patienter inom rättspsykiatrisk vård inte får rätt eller tillräckliga insatser, vilket är ett problem. / Background: Everyone in forensic care has some type of psychiatric disability and has carried out one or more criminal acts. The care is regulated in a number of laws. One part of the patient’s rehabilitation is the transition from closed to open care by so-called leave. A number of the patients that are on leave are sometimes readmitted to closed care for different reasons. These patients are sometimes referred to as “revolving door patients”. Aim: The aim was to determine different concerned personnel groups’ opinions and experiences of what is important, if a patient that is cared for according to the law of forensic care, is to be successful or unsuccessful with his/her leave. Method: A qualitative approach was chosen and two focus group interviews, with six participants in each group, were performed. The text was analyzed with the help of a qualitative content analysis. Results: Three main themes came to light that have significance as to how successful a leave is: comorbidity, how fundamental needs are taken care of and collaboration concerning the patient. 14 subthemes were found under the three main themes: correct psychiatric diagnosis, concurrent misuses, compliance in medication, social networks, employment, safe accommodation, the patient’s economy, seeing the patients needs, clear planning, knowledge and motivation, indistinct line of responsibility, collaboration prior to leave, contacts and follow-up in open care. Conclusion: Many functions are adequate in the care of patients within forensic care. Though there are deficiencies that need to be improved and developed. It is important that the patients participate in the care and that different authorities create individual conditions and flexible solutions if a leave is to be successful. Arranged economy is important if a leave is to be successful, as much of the patient’s everyday existence is affected. When the patient is unsuccessful with a leave, the reason could be that the patient’s real needs are not known, or not enough consideration has been taken to the patients needs when planning the leave. Inadequate public recourses sometimes contribute to patients, in forensic care, not receiving correct or sufficient measures (help), which is a problem.

Introdução: A readmissão de pacientes nas unidades de terapia intensiva (UTIs) está associada a piores desfechos durante a internação hospitalar. Através da análise de preditores existe a possibilidade de identificar os pacientes sob risco de readmissão e planejar possíveis intervenções visando melhorar a segurança destes pacientes. Objetivos: Avaliar o desempenho da saturação venosa central (SvcO2), do lactato, do déficit de bases (DB), dos níveis de proteína C reativa (PCR), do Sequential Organ Failure Assessment (SOFA), do Stability and Workload Index for Transfer (SWIFT) escore do dia da alta da UTI como preditores e fatores de risco para readmissão de pacientes na unidade de terapia intensiva (UTI), além de verificar a frequência de readmissões na UTI. Métodos: O estudo avaliou pacientes criticamente enfermos internados consecutivamente na unidade de terapia intensiva do Hospital Nossa Senhora da Conceição que receberem alta da UTI, no período entre Agosto/2011 e Agosto/2012. Resultados principais: Utilizando análise multivariada o SOFA e o SWIFT da alta foram identificados como fatores de risco independentemente associados à readmissão na UTI. Entretanto, com uma área sob a curva receiver operating characteristic (ROC) de 0,63 e 0,66 respectivamente, estes escores podem não ter grande aplicabilidade clínica em nossa população. A PCR, a SvcO2, o DB e o lactato não estão associados a readmissão de pacientes críticos. Conclusões: Apesar do grande impacto clínico e econômico associado à readmissão de pacientes na UTI, nossa capacidade para discriminar os pacientes sob risco de readmissão e objetivar os critérios de alta dos pacientes críticos segue inadequada. / Background: Readmission of patients in intensive care units (ICUs) is associated with worse outcomes during hospitalization. Possibly, identifying patients at risk for readmission through the analysis of predictors, some intervention may be planned for the security of these patients. Objectives: To evaluate the performance of central venous oxygen saturation (ScvO2), lactate, base deficit (BD), C-reactive protein (CRP), the Sequential Organ Failure Assessment (SOFA) score and the Stability and Workload Index for Transfer (SWIFT) score at the day of discharge from the intensive care unit (ICU) as predictors and risk factors for readmission or unexpected death among critically ill patients and to identify the frequency of readmissions in the ICU. Design: Prospective observational study. Location: academic tertiary hospital in Brazil. Patients: A total of 1,360 patients admitted to a 59 beds medical-surgical ICU from August 2011 to August 2012. Methods: We compared the characteristics and laboratory data of readmitted patients and not readmitted patients discharged from the ICU. Through multivariate analysis we identified potential risk factors independently associated with readmission. Main results: SOFA and SWIFT were identified as significant risk factors for ICU readmission. However, with an area under the ROC curve of 0.63 and 0.66, these scores would appear to have limited clinical applicability in our population. CRP, ScvO2, BD and lactate were not associated with readmission of critically ill patients. Conclusions: Perfusion and inflammatory markers are not good predictors of ICU readmission. Despite the clinical and economic impact associated with readmission in ICU, our ability to predict which patients will be readmitted is still inadequate.

Introdução: O Red blood cell distribution width (RDW) é um preditor de mortalidade em pacientes criticamente enfermos. A associação do RDW na alta da UTI com o risco de readmissão à UTI não é conhecida. Nós fizemos este estudo com o objetivo de investigar a associação entre a presença de anisocitose na alta da UTI e o risco de readmissão à UTI ou óbito inesperado na enfermaria. Métodos: Estudo de coorte retrospectivo que incluiu 813 pacientes com alta da UTI para a enfermaria em um hospital terciário de Porto Alegre, Brasil. A variável de interesse foi o RDW coletado no momento da alta da UTI. Anisocitose foi definida como RDW > 16%. Desfechos de interesse foram readmissão à UTI, óbito inesperado na enfermaria e óbito hospitalar. Hazard ratios (HR) foram estimadas usando o Modelo de Riscos proporcionais de Cox. Variáveis com P < 0.1 na análise univariada foram incluídas na análise multivariada para ajuste. Resultados: Anisocitose na alta da UTI está independentemente associada com readmissão à UTI ou óbito inesperado na enfermaria (HR: 1,682; IC 95% 1,219 – 2,322; P = 0,002). Outras variáveis associadas com este desfecho foram: idade, escore Sequential Organ Failure Assessment (SOFA) na alta da UTI e traqueostomia. Resultados significativos semelhantes foram obtidos após exclusão dos óbitos inesperados na enfermaria (HR: 2,031; IC 95% 1,428 – 2,889; P< 0,001) e para óbito hospitalar (HR: 1,716; IC 95% 1,141 – 2,580; P = 0,01). Conclusões: Anisocitose no momento da alta da UTI está independentemente associada com readmissão à UTI e óbito hospitalar. / Introduction: Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. The relationship between the RDW at ICU discharge and the risk of ICU readmission is unknown. The purpose of this study was to investigate the association between the presence of anisocytosis at ICU discharge and the risk of ICU readmission or unexpected death in the ward. Methods: This retrospective cohort study included 813 patients discharged alive from the ICU to the ward in a tertiary hospital in Porto Alegre, Brazil. The target variable was the RDW collected at the time of ICU discharge. Anisocytosis was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Hazard ratios (HR) were estimated using the Cox proportional hazards model. Variables with a value of P < 0.1 in the univariate analysis were included in the multivariate analysis for adjustment. Results: Anisocytosis at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward (HR: 1.682; 95% CI 1.219-2.322; P = 0.002). Other variables associated with this outcome included age, Sequential Organ Failure Assessment (SOFA) score at ICU discharge and tracheostomy. Similar significant results were obtained after the exclusion of unexpected deaths in the ward (HR 2.031; CI 1.428 – 2.889; P < 0.001) and for in-hospital deaths (HR 1.716; 95% CI 1.141-2.580; P = 0.01). Conclusions: Anisocytosis at ICU discharge is independently associated with ICU readmission and in-hospital death.

Introdução: Quando os indivíduos apresentam infecção do sítio cirúrgico, incluindo o sítio ortopédico, observa-se que alguns recebem tratamento e cuidados em ambiente domiciliar e não necessitam de nova hospitalização. No caso de uma readmissão, decorrente de processo infeccioso, o tratamento pode ser conservador, por meio de cuidados com a ferida cirúrgica e uso de antimicrobianos, ou ainda pode ser necessário que se submeta a uma ou mais intervenções cirúrgicas. Profissionais de saúde devem conhecer os significados e o vivido nas readmissões consequentes de infecções associadas aos procedimentos cirúrgicos. É a reflexão dessa história que está no passado que, sendo verbalizada, traz consigo experiências próprias, únicas e exclusivas. As perguntas que levaram à investigação foram: Como é estar readmitido por infecção do sítio cirúrgico ortopédico? Como a readmissão por infecção pós-operatória ortopédica é entendida no contexto pessoal, de vida familiar, e de trabalho? Que repercussões pessoais e sociais decorrentes da readmissão por infecção ortopédica podem ser percebidas pelo indivíduo? Objetivo: Compreender a experiência de indivíduos readmitidos por infecção do sítio cirúrgico ortopédico. Método: Pesquisa qualitativa fundamentada na Fenomenologia Existencial de Martin Heidegger. Participaram desse estudo onze indivíduos readmitidos em função de infecção do sítio cirúrgico ortopédico, em um hospital público, em Belo Horizonte, Minas Gerais, que atenderam aos critérios de inclusão e exclusão. Os depoimentos foram obtidos por meio de entrevista, entre março de 2014 e abril de 2015, a partir da seguinte questão norteadora: Como é para você estar readmitido por infecção do sítio cirúrgico ortopédico? Resultados: Os depoimentos coletados e analisados à luz da Fenomenologia existencial desvelaram o ser-aí-readmitido por infecção pós-operatória ortopédica. Sentiu medo e insegurança em relação ao que desconhecia; expressou frustração, pois estava acontecendo algo que não esperava acontecer; e observou o passar de um tempo que não significou o quantitativo de dias ou semanas em que ali estava presente, mas, ao contrário, a ausência de ser em seu cotidiano. Nesse momento, percebeu-se descuidado, e a comunicação em saúde marcou o descuidado quando julgou não ter sido acolhido e ouvido em sua história, em seu existir. Assim, entendeu as relações sociais comprometidas, que, algumas vezes, tangenciaram o rompimento. Apegar-se a Deus foi uma estratégia de conforto e de proximidade com um ser divino que poderia afastar aquilo que se aproximava e ameaçava: complicações, sequelas e morte. Conclusões: Os resultados desse estudo sinalizam a necessidade de aprofundar o conhecimento das dimensões que envolvem o cuidar com vistas ao desenvolvimento de competências, a partir das subjetividades dos momentos vividos no processo saúde-doença. Para isto, conhecer é primordial, refletir possibilita compreender, quando, então, a simples habilidade de ouvir toma o caminho da escuta qualificada, em que as atitudes são possíveis e o profissional de saúde desenvolve a capacidade para o cuidado em seu verdadeiro significado. O cuidado que transcende o saber fazer e tenta alcançar o saber fazer sensível. / Introduction: When people develop a surgical site infection, including the orthopedic site, it can be observed that some receive treatment and care in the home environment, not requiring re-hospitalization. In the case of readmission due to infectious process, treatment can be conservative through caring for the surgical wound and antimicrobial use, or it can require one or more surgical interventions. Health professionals should know the meanings and the experience of readmissions as a consequence of infections associated with surgical procedures. It is this reflection about past reports stories that when verbalized reveal unique and exclusive experiences. The questions leading to the investigation were: How does it feel to be readmitted for an orthopedic surgical site infection?; How is readmission due to an orthopedic post-operative infection understood in the personal, family life and work context?; What personal and social repercussions from orthopedic infection readmission can be perceived by the individual? Objective: To understand the experience of individuals readmitted due to orthopedic surgical site infection. Method: A qualitative research based on the Existential Phenomenology of Martin Heidegger. 11 individuals readmitted due to orthopedic surgical site infection in a public hospital in Belo Horizonte, Minas Gerais, who met inclusion and exclusion criteria participated in this study. Their statements were obtained through interviews between March 2014 and April 2015, from the following guiding question: How is it for you to be readmitted due to an orthopedic surgical site infection? Results: The testimonies that were collected and analyzed in the light of the Existential Phenomenology unveiled a specific readmitted-being-there feeling from orthopedic post-operative infection. They felt afraid and insecure regarding the unknown; expressed frustration because something that they did not expect would happen was happening; and the passing of time was perceived that did correspond to the amount of days or weeks in which they were present, but, instead, a feeling of being absent from being in their daily lives. At that point, a feeling of neglect was perceived, with health communication characterizing this neglect, making them feel like they have not been welcomed, nor had their story, their existence, heard. Therefore, understanding the impaired social relationships, which sometimes affected the disruption. Becoming attached to God was a comfort strategy of proximity to a divine being who could ward off the treatments that were coming: complications, sequelae and death. Conclusions: The results of this study indicate the need to deepen the knowledge of the dimensions involving care with a view to develop skills from the subjectivity of the experiences lived in the health-illness process. For this, understanding is essential, and reflection enables understanding, whereupon the simple ability to listen leads to qualified listening, where attitudes are possible and the health professional develops the ability to care for its true meaning; the care that transcends know-how and tries to achieve sensitive know-how.

Introdução: O Red blood cell distribution width (RDW) é um preditor de mortalidade em pacientes criticamente enfermos. A associação do RDW na alta da UTI com o risco de readmissão à UTI não é conhecida. Nós fizemos este estudo com o objetivo de investigar a associação entre a presença de anisocitose na alta da UTI e o risco de readmissão à UTI ou óbito inesperado na enfermaria. Métodos: Estudo de coorte retrospectivo que incluiu 813 pacientes com alta da UTI para a enfermaria em um hospital terciário de Porto Alegre, Brasil. A variável de interesse foi o RDW coletado no momento da alta da UTI. Anisocitose foi definida como RDW > 16%. Desfechos de interesse foram readmissão à UTI, óbito inesperado na enfermaria e óbito hospitalar. Hazard ratios (HR) foram estimadas usando o Modelo de Riscos proporcionais de Cox. Variáveis com P < 0.1 na análise univariada foram incluídas na análise multivariada para ajuste. Resultados: Anisocitose na alta da UTI está independentemente associada com readmissão à UTI ou óbito inesperado na enfermaria (HR: 1,682; IC 95% 1,219 – 2,322; P = 0,002). Outras variáveis associadas com este desfecho foram: idade, escore Sequential Organ Failure Assessment (SOFA) na alta da UTI e traqueostomia. Resultados significativos semelhantes foram obtidos após exclusão dos óbitos inesperados na enfermaria (HR: 2,031; IC 95% 1,428 – 2,889; P< 0,001) e para óbito hospitalar (HR: 1,716; IC 95% 1,141 – 2,580; P = 0,01). Conclusões: Anisocitose no momento da alta da UTI está independentemente associada com readmissão à UTI e óbito hospitalar. / Introduction: Red blood cell distribution width (RDW) is a predictor of mortality in critically ill patients. The relationship between the RDW at ICU discharge and the risk of ICU readmission is unknown. The purpose of this study was to investigate the association between the presence of anisocytosis at ICU discharge and the risk of ICU readmission or unexpected death in the ward. Methods: This retrospective cohort study included 813 patients discharged alive from the ICU to the ward in a tertiary hospital in Porto Alegre, Brazil. The target variable was the RDW collected at the time of ICU discharge. Anisocytosis was defined as an RDW > 16%. Outcomes of interest included readmission to the ICU, unexpected death in the ward and in-hospital death. Hazard ratios (HR) were estimated using the Cox proportional hazards model. Variables with a value of P < 0.1 in the univariate analysis were included in the multivariate analysis for adjustment. Results: Anisocytosis at ICU discharge was independently associated with readmission to the ICU or unexpected death in the ward (HR: 1.682; 95% CI 1.219-2.322; P = 0.002). Other variables associated with this outcome included age, Sequential Organ Failure Assessment (SOFA) score at ICU discharge and tracheostomy. Similar significant results were obtained after the exclusion of unexpected deaths in the ward (HR 2.031; CI 1.428 – 2.889; P < 0.001) and for in-hospital deaths (HR 1.716; 95% CI 1.141-2.580; P = 0.01). Conclusions: Anisocytosis at ICU discharge is independently associated with ICU readmission and in-hospital death.

Introdução: A readmissão de pacientes nas unidades de terapia intensiva (UTIs) está associada a piores desfechos durante a internação hospitalar. Através da análise de preditores existe a possibilidade de identificar os pacientes sob risco de readmissão e planejar possíveis intervenções visando melhorar a segurança destes pacientes. Objetivos: Avaliar o desempenho da saturação venosa central (SvcO2), do lactato, do déficit de bases (DB), dos níveis de proteína C reativa (PCR), do Sequential Organ Failure Assessment (SOFA), do Stability and Workload Index for Transfer (SWIFT) escore do dia da alta da UTI como preditores e fatores de risco para readmissão de pacientes na unidade de terapia intensiva (UTI), além de verificar a frequência de readmissões na UTI. Métodos: O estudo avaliou pacientes criticamente enfermos internados consecutivamente na unidade de terapia intensiva do Hospital Nossa Senhora da Conceição que receberem alta da UTI, no período entre Agosto/2011 e Agosto/2012. Resultados principais: Utilizando análise multivariada o SOFA e o SWIFT da alta foram identificados como fatores de risco independentemente associados à readmissão na UTI. Entretanto, com uma área sob a curva receiver operating characteristic (ROC) de 0,63 e 0,66 respectivamente, estes escores podem não ter grande aplicabilidade clínica em nossa população. A PCR, a SvcO2, o DB e o lactato não estão associados a readmissão de pacientes críticos. Conclusões: Apesar do grande impacto clínico e econômico associado à readmissão de pacientes na UTI, nossa capacidade para discriminar os pacientes sob risco de readmissão e objetivar os critérios de alta dos pacientes críticos segue inadequada. / Background: Readmission of patients in intensive care units (ICUs) is associated with worse outcomes during hospitalization. Possibly, identifying patients at risk for readmission through the analysis of predictors, some intervention may be planned for the security of these patients. Objectives: To evaluate the performance of central venous oxygen saturation (ScvO2), lactate, base deficit (BD), C-reactive protein (CRP), the Sequential Organ Failure Assessment (SOFA) score and the Stability and Workload Index for Transfer (SWIFT) score at the day of discharge from the intensive care unit (ICU) as predictors and risk factors for readmission or unexpected death among critically ill patients and to identify the frequency of readmissions in the ICU. Design: Prospective observational study. Location: academic tertiary hospital in Brazil. Patients: A total of 1,360 patients admitted to a 59 beds medical-surgical ICU from August 2011 to August 2012. Methods: We compared the characteristics and laboratory data of readmitted patients and not readmitted patients discharged from the ICU. Through multivariate analysis we identified potential risk factors independently associated with readmission. Main results: SOFA and SWIFT were identified as significant risk factors for ICU readmission. However, with an area under the ROC curve of 0.63 and 0.66, these scores would appear to have limited clinical applicability in our population. CRP, ScvO2, BD and lactate were not associated with readmission of critically ill patients. Conclusions: Perfusion and inflammatory markers are not good predictors of ICU readmission. Despite the clinical and economic impact associated with readmission in ICU, our ability to predict which patients will be readmitted is still inadequate.

Ao se considerar a importância da busca de indicadores que determinam, tanto a alta dos pacientes das unidades de terapia intensiva (UTIs) como o risco de óbito e readmissão dos internados nessa unidade, este estudo teve como objetivos: caracterizar os pacientes internados em UTIs de hospitais que tenham unidades intermediárias quanto aos dados demográficos e clínicos; descrever a mortalidade e a unidade de destino após a alta da UTI e a freqüência de readmissão nessas unidades; comparar as médias do Nursing Activities Score (NAS), Simplified Acute Physiology (SAPS II) e Logistic Organ Dysfunction (LODS) no primeiro e último dia de internação na UTI; identificar os fatores associados com a alta, óbito e readmissão dos pacientes em UTI na mesma internação hospitalar. Trata-se de um estudo prospectivo longitudinal de pacientes adultos internados em UTIs gerais de dois hospitais governamentais e dois não governamentais do Município de São Paulo que possuíam unidades intermediárias. A casuística compôs-se de 500 pacientes adultos admitidos nessas UTIs. Os dados coletados foram referentes as primeiras e últimas 24 horas de permanência na UTI, porém os pacientes foram acompanhados até a alta hospitalar para identificação das readmissões. Os resultados mostraram predomínio de indivíduos idosos (55,80%), do sexo feminino (56,60%), a maior parte procedente do Pronto-Socorro/Atendimento (37,60%) e tempo de permanência na UTI entre um e dois dias (36,60%). Os antecedentes e os motivos de internação mais freqüentes foram relacionados às doenças do aparelho circulatório. As médias dos escores, no primeiro dia de internação na UTI, foram SAPS II, 37,41, LODS, 4,32 e NAS, 62,13. No último dia de internação, o valor médio do SAPS II foi de 36,15, do LODS, 4,2 e do NAS, 52,17. Os pacientes com alta da UTI apresentaram no último dia de internação, a média desses escores inferior à de admissão. Nos indivíduos que morreram, as médias dos escores SAPS II e LODS foram superiores no último dia de internação na UTI em relação aos valores de admissão; já as médias do NAS foram similares. Os pacientes readmitidos apresentaram na alta da UTI diminuição da média dos escores, porém essa diferença só alcançou níveis significativos quando o NAS foi o indicador utilizado. A mortalidade foi 20,60% durante a internação na UTI, a maioria dos pacientes foi transferida para unidade intermediária e aproximadamente, 9% foram readmitidos. Os pacientes que foram encaminhados à unidade intermediária diferiram dos que foram para unidade de internação em relação à idade, procedência, antecedentes, motivo de internação, SAPS II na admissão e NAS na admissão e alta. Os pacientes que morreram, apresentaram maior tempo de internação, escores de gravidade mais altos na admissão e, imediatamente, antes do óbito. No último dia de internação na UTI, o NAS foi mais elevado entre os que morreram. Para o grupo de readmitidos, somente antecedentes relacionados a doenças infecciosas e parasitárias, doenças do aparelho geniturinário e o LODS na admissão foram diferentes se comparados aos não readmitidos / Considering the relevance of collecting indicators to define either the discharge of patients from the Intensive Care Units (ICUs) or risk of death and readmission of interned patients into these units, this study had as objectives: - to characterize the patients interned in ICUs in hospitals with intermediate care units according to demographical and clinical data; - to describe mortality, unit of destination after ICU discharge and frequency of readmission into these units - to compare the averages of the Nursing Activities Score (NAS), Simplified Acute Physiology (SAPS II) and Logistic Organ Dysfunction (LODS) during the first and the last day of internment in the ICU; - to identify the factors associated with the discharge, death and readmission of patients into the ICU, during the same hospital internment. This is a longitudinal prospective study of adult patients interned in general ICUs of two public hospitals and two private hospitals of the City of São Paulo, which had intermediate care units. The casuistry was composed of 500 adult patients who were interned in these ICUs. The collected data referred to the first and the last 24 hours spent in the ICU, however, a follow-up of the patients was made until their discharge in order to identify readmissions. The results show a predominance of elderly individuals (55.8%), of female gender (56.6%), with the larger number coming from the Emergency Room (37.6%) and patients who spent between one and two days in the ICU (36.6%). The previous problems and the main motives for internment were related to circulatory system diseases. The average scores during the first day in the ICU were SAPS II (37.41), LODS (4.32) and NAS (62.13%). During the last day of internment, the average scores were SAPS II (36.15), LODS (4.2), and NAS (52.17%). Patients who had been discharged from the ICU presented, during the last day of internment, an average in these scores inferior to those registered on their entry day. For the individuals who died, the average SAPS II and LODS scores were superior to those of the entry day in the ICU, nevertheless, the NAS averages were similar. The readmitted patients had, at the time of discharge from the ICU, less than average scores in SAPS II, LODS and NAS. This difference, however, only reached significant levels when the NAS indicator was applied. The death rate was 20.6% during the ICU internment, the majority of the patients were transferred to an intermediate care unit and approximately 9% were readmitted. Patients, who were transferred to the intermediate care unit, differed from those who went to a general nursing unit according to age, origin, antecedents, motive for internment, SAPS II during their entry, NAS during their entry and discharge. Patients who died presented longer internment time and had more severe scores at their entry into the ICU and immediately before death. The NAS during the last internment day in the ICU was higher for those who died. For the readmitted group, only antecedents related to contagious and parasitic diseases, genitourinary system diseases, and LODS at entry were different when compared to those of patients who were not readmitted into the ICU

Abstract Hospital treatment of chronic obstructive pulmonary disease in primary and secondary health care and changes in treatment from 1972 to 2004 were examined by means of the treatment register and the register of deaths. During the study period, the patients with a principal diagnosis of chronic obstructive pulmonary disease (COPD) underwent 356,066 treatment periods. In 1980–1984, 44.3% of the patients hospitalized the first time for COPD died within five years after their treatment period, and in 1990–1994, 50.9% died after their treatment period. According to Cox’s age-adjusted regression model, mortality increased among both men (Hazard Ratio 1.093, 95% CI 1.055–1.133) and women (HR 1.138, 95% CI 1.061–1.221). The number of long-term, over-90-day periods of inpatient treatment of COPD patients in university and central hospitals decreased 97.6% and the number of days of treatment decreased 98.4% between 1972–1976 and 1997–2001. Correspondingly, these treatment periods increased 7.6% in primary care hospitals and the number of days of treatment decreased 47.6%. In 1995–2001 the number of inpatient periods due to acute exacerbations of COPD increased 10.9%, but the number of days of treatment decreased 8.5%. The growth in age-adjusted treatment periods was 0.8% among men and 18.5% among women. The number of treatment periods increased 36.8% in general practice wards and 17.8% in wards for respiratory diseases, while they decreased 22.3% in internal medicine wards. General practitioners sent 5.1% of patients admitted to a primary care hospital with acute exacerbation of COPD to a secondary care hospital. The age- and gender-adjusted risk of death of patients managed by a general practitioner was 0.83 (95% CI 0.75–0.91) compared with those managed by a pulmonary specialist. Patients treated in primary care had a 1.74 times greater risk of being readmitted within a week after being released from inpatient treatment for acute exacerbations of COPD compared with patients treated in secondary care. The strategic policies of the 1980s, changes in the service structure, the national guidelines for the prevention and treatment of COPD issued in 1998, the valid treatment recommendation, and new treatments and medication have made treatment of COPD patients more effective. The emphasis has shifted to outpatient care and primary health care, where sufficient resources and education must be insured in order to guarantee good quality. / Tiivistelmä Tutkimuksessa selvitettiin hoitoilmoitus- ja kuolinsyyrekisterin avulla keuhkoahtaumataudin sairaalahoitoa ja sen muutoksia perusterveydenhuollossa ja erikoissairaanhoidossa vuosina 1972–2004. Tutkimusaikana oli 356 066 hoitojaksoa niillä potilailla, joiden päädiagnoosi oli keuhkoahtaumatauti (KAT). Vuosina 1980–1984 olleen ensimmäisen KAT:sta aiheutuneen sairaalahoitojakson jälkeen potilaista kuoli viiden vuoden kuluessa 44,3 % ja vastaavasti vuosien 1990–1994 hoitojakson jälkeen 50,9 %. Coxin regressiomallilla iän ollessa vakioituna kuolleisuus lisääntyi sekä miehillä (Hazard Ratio 1,093, 95 % CI 1,055–1,133) että naisilla (HR 1,138, 95 % CI 1,061–1,221). Pitkäaikaiset, yli 90 hoitopäivää jatkuneet, sairaalahoitojaksot vähenivät KAT-potilailla yliopisto- ja keskussairaaloissa 97,6 % ja hoitopäivät 98,4 % ajanjaksojen 1972–1976 ja 1997–2001 välillä. Vastaavasti terveyskeskussairaaloissa nämä hoitojaksot lisääntyivät 7,6 % ja hoitopäivät vähenivät 47,6 %. Vuosina 1995–2001 olleiden KAT:n akuuttien pahenemisvaiheiden sairaalajaksojen määrä kasvoi 10,9 %, mutta hoitopäivien määrä väheni 8,5 %. Ikävakioitujen hoitojaksojen kasvu miehillä oli 0,8 % ja naisilla 18,5 %. Hoitojaksot lisääntyivät yleislääketieteen erikoisalan osastoilla 36,8 % ja keuhkosairauksien osastoilla 17,8 %, kun taas sisätautien osastoilla ne vähenivät 22,3 %. Yleislääkäri lähetti erikoissairaanhoitoon 5,1 % terveyskeskuksen vuodeosastolle otetuista akuuteista KAT:n pahenemisvaiheen potilaista. Yleislääkärin hoitovastuulla olleiden potilaiden ikä- ja sukupuolivakioitu kuoleman riskisuhde oli 0,83 (95 % CI 0,75–0,91) verrattuna keuhkolääkärin vastuulla olleisiin potilaisiin. Perusterveydenhuollossa hoidetuilla potilailla oli 1,74 kertainen riski joutua uudelleen sairaalahoitoon viikon kuluessa KAT:n akuutin pahenemisvaiheen sairaalahoidon jälkeen verrattuna erikoissairaanhoidossa hoidettuihin potilaisiin. 1980-luvun strategiset linjaukset, palvelurakennemuutokset ja kansalliset ohjeet keuhkoahtaumataudin ennaltaehkäisystä ja hoidosta vuodelta 1998 ja Käypä hoito -suositus sekä uudet hoitomuodot ja lääkkeet ovat tehostaneet keuhkoahtaumapotilaan hoitoa. Painopiste on siirtynyt avohoitoon ja perusterveydenhuoltoon, jossa on huolehdittava riittävästä resursoinnista ja koulutuksesta hyvän laadun varmistamiseksi.

Congestive heart failure (CHF) is associated with a significant economic burden that includes frequent emergency department visits, hospitalizations, and readmissions. The purpose of this study was to examine the differences, if any, between hospital readmission rates and insurance reimbursement rates for non-Hispanic Black and White CHF patients in California. The theoretical framework was Bandura's social cognitive theory. Secondary data for this quantitative study were obtained from the Office of Statewide Health Planning and Development and State Inpatient Databases from Healthcare Cost and Utilization for calendar year 2014-2016. A t-test and Levene's test for equality of variance were conducted on a sample of 11,905 patient records from 675 hospitals in California; the readmission discharge data and insurance reimbursement rates were analyzed by ethnicity and payer type. The results indicated that there was not a statistically significant difference between non-Hispanic Blacks as compared to non-Hispanic Whites in relation to readmission rates (M = 49.6, SD = 38.28) or insurance reimbursement rates (M = 50.88, SD = 36.52). Non-Hispanic Blacks had a higher readmission rate (36%) as compared to Whites (29%), and although these results are not significant, they support the need for healthcare professionals to develop programs that meet the needs of the community. The results of this study contribute to positive social change by providing information that healthcare professionals may be able to use to decrease CHF readmissions and improve access to care for non-Hispanic Blacks and other vulnerable patient groups.

Introduction: A recent study at the acute admission unit (AAU), revealed that 13.5 percent ofall patients discharged from the department, were readmitted within 30 days during 2018. Inthe group of 80 years and above, the cause for re-admission was multifactorial. Aim: To identify factors that are associated with unplanned re-admission, palliative decision,or death within 30 days after discharge from the AAU, in patients of 80 years or above. Anotheraim is to examine if longer hospital stay, patient discharge planning and fast follow-up canprotect against these outcomes. Methods: A retrospective cohort study comprising 287 patients. Data on age, sex, length ofstay, comorbidities (Elixhauser comorbidity index), frailty (Clinical frailty scale), NationalEarly Warning Score (NEWS), social status, home care, lab values and outcome were collected.All variables were analyzed using Chi-square test with univariate and multivariate logisticregression, and a p-value &lt; 0.05 was considered statistically significant. Results: 276 patients were included. A NEWS ≥ 3 was associated with significantly increasedrisk for poor outcome (odds ratio 2.4). Living with someone without municipal support wasassociated with a significantly decreased risk for poor outcome (odds ratio 0.21). Conclusions: The results indicate that it is crucial to stabilize patients of 80 years or abovebefore discharge. And that living with someone without municipal support is a protective factor.